If you’re not having good days and bad days as a medical student, you’re just not trying hard enough. This whole experience is at least partially preparation for the real world of medicine–that there’s two sides to every story, that there’s an art to dealing with all sorts of people, and that you must learn from every encounter you have with a patient.

So there I am, two weeks ago, with a good day and a bad one in the same 24 hour period. It starts off with a patient with an autoimmune disease. I go see the patient with a fellow. (A fellow is a doctor done with residency that is now specializing.) This fellow is well-liked by all of his patients, as far as I can tell. His interview style is very focused, however. Question, answer. Follow-up question, follow-up answer with tangential comment… question to get interview back on track.

Today we walk in to see this patient, and I can already tell he’s a little agitated, or frustrated or uncomfortable, for whatever reason. I don’t know if the fellow doesn’t pick up on this, or just ignores it. Fellow asks a bunch of questions about how the patient is feeling, the patient says crummy, that he’s constantly aching, and isn’t getting any relief from his current medications. Fellow addresses this to some degree, but doesn’t offer any solutions. Fellow is looking down at his notes; I’m sitting on the exam table watching the interaction from the sidelines. The patient starts to say, “Well then, here’s what I’d like from you,” but is cut-off by the fellow’s next question, something about “any nausea or vomitting?” Aaaaand, the fellow has officially lost the patient. For the rest of the interview, the patient answers quickly with rapid nodding, wanting to get back to his request. I’m thinking to myself, “Do I say something? I mean, of course I say something, but how do I say it without butting in–” And then I realize I’m Super Patient Advocate, and it’s my duty to step in. I wait for a pause, which the patient then takes to start asking again, and gets interupted a second time. The patient is now eyeing me, and I’m kind of nodding in agreement, trying to let him know I’ll say something. The patient is getting more and more visibly annoyed with the fellow, but the fellow can’t see because he’s looking down taking notes. Finally, finding a half-second pause somewhere, I blurt out, “Did you want to say something?” to the patient, and he gets his request in for some pain medications.

Now, I have to admit, this encounter was fascinating. When presenting to the attending, the fellow described the patient as “a kind of cantankerous gentleman,” and I could clearly see the reason the fellow found the patient cantankerous–the patient was annoyed with being ignored! I’d be pretty damn cantankerous too.

At the end of the visit, I got a direct “thank you” from the patient, and I nodded, somewhat apologetically. In the end, each party got what they needed from the appointment, but it put both parties on the defensive to some degree.

Which makes my second encounter all the sweeter. That same day, in lung clinic, I pick up a chart of a new patient and start taking notes from his file (he’s an hour early, by the way, but there were no other patients at the time). He’s got a number of severe medical problems that have caused very catastrophic complications, making him wheelchair-bound. (He’s been waiting in the room maybe 7 minutes while I’ve been reviewing his file, and asking a question about a drug’s effects on the kidney.) Just as I’m about to stand up, he starts to leave, complaining to the nurse about how long he’s been waiting (he’s now 53 minutes early). I walk toward the room to introduce myself and apologize for making him wait, and he makes some snide remark to me about how he was just getting ready to leave. I go in, we talk, and immediately get the sense that for whatever reason, he hates hospitals and doctors. (I later find out he has good reason to be skeptical; he’s had several major medical problems caused by shoddy medical care.) He talks to me about how terrible doctors are, and doesn’t really know why he’s at this appointment, continuing with a tone I interpret as him blaming me for forcing him to come today.

I finish my history and physical, and tell him I’ll be back “in a bit.” I probably should have warned him that since he was so early, he would have to wait awhile so I could discuss his case with the attending (lesson learned). Granted, it’s still 20 minutes before his appointment is even scheduled. He opts to leave the door open, which is right across the hall from the workroom, and he stares at me while I work on the computer and talk with the residents, probably thinking I’m ignoring him, or not doing anything productive, just making him wait. 20 minutes later, the attending is ready for me, and I present his case quietly, as he continues to stare me down from across the hall. We then go in together to see him, and he loudly comments, “Finally, a real doctor.” I quickly retort, “Yes, I just play one on TV,” and go along with the joke. We see him, and he talks about buying his 16 year-old daughter cigarettes, and I can fully tell we are from practically different planets. As we’re leaving, he complains again to me about having to wait (it’s now 15 minutes into his scheduled appointment time), and that does it. I turn around, pissed, and get about two words out about his appointment time, “Well, it’s…” and I smartly bite my tongue, turn back around, and just walk away.

He knows he’s gotten to me. And I’ll admit it: he had. From the moment I entered the room. The community health side of me kept reminding me, “There’s probably a great reason why he didn’t seek medical attention early and now has all these severe problems that he’s angry with: maybe he didn’t have health insurance, or he knew a doctor that was a total jerk, or he didn’t have the education to recognize the warning signs of his disease, or he was too busy working three jobs to support his family that he never found time for it.” But with each jab (and the fact that I took it personally), the individualist crept in. “This is his own fault. He didn’t seek medical attention for a long time, he didn’t take his doctors’ advice, he thought medicine was a load of crap. He screwed up, big time, and now he’s paying the price.”

And therein lies probably one of my biggest challenges of being a physician: not taking things personally, not getting so easily annoyed, and continuing to provide the highest-quality care to all my patients, no matter who they are, or what they say, or how they react to me. And it’s definitely a challenge. Other professions don’t carry such an obligation. Part of the reason I’m writing this out is to get a handle on it, understand it, and do a better job next time. I think sometimes it’s soothing to rationalize behavior as pathology–that my patient has a personality disorder, and that’s why he was being such a jerk to innocent little me–but I don’t think that’s right, either.

I can see why physicians and residents get jaded now. For me so far, the late night pages didn’t seem like they’d be that bad. And while scut work sucks, it’s not jade-developing. But being treated poorly by someone you’re trying to help could turn me bitter pretty quick.

But there’s a part of me that wonders if my patient was annoyed with me for the same reason the first patient was annoyed with the fellow, and maybe that’s what frustrates me: not knowing if I could have done better.

Comments

Pat Ciufo:

Dear Graham,if there’s one thing I’ve learned after 24yrs of nursing,it’s that you can never offer too much information-even if you think the patient should know it,or may not grasp all of it-as in telling the patient you had to wait for the attending to review his case.Always listen to your patient,and try to address what’s important to him(as you did)Last thing-making mistakes is the best way to learn things-you’ll(hopefully)never forget the lesson. P.S.you young’uns are the best,and fun to work with-comic relief and a breath of fresh air all at once. Pat

Learning not to take things personally will take some time – but it’s an essential skill. What’s really tough is learning to find the grain of truth in the pile of BS. As long as you keep looking at how things might have gone better, you’ll acquire those skills.

genevieve:

the day may start out fantabulous, then all it takes is a cranky patient, and you wonder, what went wrong? why doesn’t he think i’m doing what is in his best interest? on the other hand, i’ve talked with patients who have major grudges with the specialists and medical officers who deal with them whilst in the ward, but are so sweet and nice to us medical students. and then your article just hits: will we as drs later on forget our bedside manners and really communicate with the patients, and manage the disease not the patient?

Graham, what you described (so nicely) happens to all of us. Whether we be patients, med students, carpenters, pastors, whatever.

Not to get all shrinky on you, but it may be helpful to stay mindful of these things–you know, to reflect on these events and ponder *why* you did (or did not) get irked. That’ll help keep you from getting bitter which will ultimately help your patients.

kcd:

oh my god, this is my favorite post of yours EVER and yours is already one of my top 3 blogs. thank you SO MUCH for putting this all into words. i was presenting a case to a radiologist today and she made some remark and as i was walking down the hall, i thought, “oh! that might have had nothing to do with me or my technical proficiency!” D’OH!

i can’t offer the more-experienced-and-wise comments such as the prior ones, but i am so grateful for the articulate way you told about your day. thank you for your self-honesty. and, by the way, how the hell do you print from this blog? b/c i want to keep your story about these 2 patients to, er, ruminate on.

ALL THE BEST TO YOU. peace out, dude.

kcd

Sara:

oh! that feeling. This is my first comment here, but I really like this page. You did good with your patents. I`m a medical student myself but in Hungary. where all what you will find is that second type of patient. ok, not all, but many of them. I would start the conversation with him as telling him(very kindly) that he came an hour earlier than he was supposed to, BUT I will find the time to examine him. So he would feel u care for him even earlier, anyone would. We do have to tell the patients if they are not fair with us, but not being angry of them, simply as a fact, and stay kind to them. I`ve seen many time (mostly from nurses) how to handle these situations. Always stay kind, even when you feel they are angry with all the medicals. Maybe you`ll be the one who will turn their feelings…
Best of luch to you, and to all the student in the same boat!

This was such a good post. Thank you. Reminds me of the frustration many people in the service industry feel when they answer the same question for the 20th or nth time… in a row [and the people were lined up one after the other, about 30 cm apart!].

xlee:

It is a must for a person to be real humanistc before being a doctor, caring how others feel, which is oftentimes ignored by medical students stuck in the piles of medicine books. Good post!

great post, it brings ups so many good points. the frustrating thing in the hospital was always the rigid hierarchy between patients, students, residents, fellows, etc. too militaristic for it’s own good.

I’ll second Maria on this one. Sooner or later it gets to everyone. That’s part of working with the public to help them with their issues (problems.) There are as many ways to deal with this as there are people… I’d hope there are some folks you can talk to that can help you out. For me, I concentrate on the person’s issue. If they bring up side comments intending to frustrate, just go right back to the issue at hand. Ultimately, that is probably what they really want addressed.

Welcome!

This is a medical weblog--a collection of thoughts about medicine, medical training, and health policy--written by a fifth-year medical student.

I recently stopped blogging, as I graduated from medical school and I'm now a physician in my residency training in New York City. But feel free to read and enjoy!